A randomized trial of direct decompressive surgical resection in the treatment of spinal cord compression caused by metastasis

Reviewer: Ryan Smith, MD
OncoLink
Last Modified: June 2, 2003

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Presenter: R. Patchell
Presenter's Affiliation: University of Kentucky
Type of Session: Plenary

Background

  • Cord compression by metastatic disease is a large problem in cancers that has the propensity to spread to bone.
  • As prostate cancer, breast cancer, and lung cancer all commonly spread to bone, this represents a huge problem
  • Cord compression is an oncologic emergency that, if not treated correctly and promptly, can and will result in many neurologic deficiencies with a resultant (dramatic) decrease in quality of life
  • Radiation therapy tends to arrest disease, but only rarely reverses neurologic sequelae
  • Previously, surgical treatment for cord compression consisted of laminectomy, which rarely helps and often results in spinal destabilization. However, new methods of direct decompression has been developed with increased efficacy demonstrated in smaller studies
  • This study investigates direct decompression on the treatment of cord compression

Materials and Methods

  • 101 patients with cord compression from metastatic tumor spread comprised the study group
  • Patients were randomized to decompressive surgery followed by radiotherapy within 14 days vs. radiotherapy alone
  • Treatment was required to start within 24 hours of MRI diagnosis
  • Patients had to have at least one sign or symptom other than pain and were required to have only one site of cord compression (not cauda equinal)
  • Patients could not be paraplegic for >48 hours or have extremely radioresponsive tumors (e.g. lymphoma, myeloma)
  • Crossover into the surgical arm was allowed if deterioration of neurologic function continued after beginning radiation therapy
  • Primary endpoint was maintenance of ambulation, with secondary endpoints of continence, survival, the Frankel and American Spinal Injury Associated Scores (measuring neurologic function), and the ASIA score (measuring muscular function)

Results

  • Patients treated with decompressive surgery retained the ability to walk significantly longer than those treated with radiation alone (126 days vs. 35 days, p=.006)
  • Patients treated with surgery had higher maintainenance of continence and higher neurological and muscular function scores
  • Patients treated with decompressive surgery had a 3 fold reduction in amount of corticosteroids required and a 12 fold reduction in the amount of narcotics used
  • There was a trend toward increased survival in the surgical arm (129 days vs. 100 days, p=.08)
  • In the 32 patients entered on study who had already lost the ability to walk, 56% regained function if treated by surgery
  • In the 10 patients who crossed over onto the surgical arm, 3 of them regained the ability to walk
  • Toxicities were minor

Author's Conclusions

  • Patients with cord compression treated with decompressive surgery and postoperative radiation therapy maintained the ability to walk significantly longer than those treated with radiation alone
  • If function was already lost, there is a greater than 50% chance of regaining function with surgical decompression, which was three times the rate of radiation alone
  • There was a drastic reduction in steroid and narcotic use
  • Surgical decompression works better as an initial treatment, rather than salvage therapy

Clinical/Scientific Implications

    This report shows impressive results for surgical decompression with postoperative radiation therapy for patients with cord compression. This is an extremely important finding for patients in terms of quality of life. Noted is the patients' maintenance of their ability to walk was almost the length of their survival, meaning that patients had full function when they succumbed to their disease. Another impressive result is that >50% of patients regained the ability to walk with surgical treatment. This is substantially better than any data previously reported. In addition, there is much less narcotic use, leading to the assumption that surgery led to quicker or longer lasting pain relief. However, many patients with cord compression from metastatic spread have end-stage disease. Therefore, they are commonly very ill and lack the conditioning to undergo decompression, from either a surgical or anesthesia standpoint. Hence, though this data is impressive, the number of patients it will actually apply to remains to be seen. For the vast number of patients who will not be surgical candidates, immediate radiation therapy will remain the treatment of choice.

Oncolink's ASCO Coverage made possible by an unrestricted Educational Grant from Bristol-Myers Squibb Oncology.


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